Context and executive summary
This report is the summary output of an intensive piece of work – commissioned by NHS London and co-delivered with Transformation Nous over a five-week period. The objective of this work was to understand and quantify the continuing impact of the Covid-19 pandemic, by comparing to a pre-Covid baseline.
Specifically, the work focused on understanding how the operating capacity and efficiency of Urgent and Emergency Care (UEC) in the London region was affected. Critically, it also generated recommendations to mitigate these effects, in preparation for Winter 2022/23.
We worked with two hospitals, Kingston and Chelsea & Westminster, to generate insights that are transferrable across London (and likely beyond).
Our initial hypothesis was that the most significant continuing effects of the Covid-19 pandemic would come from protocols to mitigate transmission of the disease itself i.e., Infection Prevention & Control measures and Covid testing regimes (See Exhibit 1).
In reality, we found that the biggest challenge facing hospitals was a disruption to flow out of the hospital – and the knock-on effect further down the pathway. This knock-on effect was not linear, but amplified closer the ‘front-door’ of the hospital.
A 10% decrease in patients being discharged from the wards (with an equivalent increase in average length of stay (aLoS)), translates into a ~15-20% decrease in patients through the assessment units (as aLoS goes up). The Emergency Department (ED) is where the challenge is most visible, pressure is heightened, and where risks to patients become most significant. We have seen an increase of up to 50% in aLoS within the ED (See Exhibit 2).
This is the new reality of the UEC we will explore in the following sections, in addition to challenges such as mental health within the ED and increasing complexity of site management.
Inpatient wards
Challenges facing acute hospitals begin at the end of the in-hospital patient pathway. Comparing the months directly preceding Covid-19 to the first few months of 2022, we have seen a 10% drop in the number of patients being discharged from inpatient wards.
As expected, over the same period the aLoS of patients has increased. All else being equal, aLoS increases will be equivalent to a fall in discharges, as is the case at Kingston Hospital. At Chelsea &Westminster, bed base adjustments over the analysis period, and other factors specific to the site, mean that the increase is smaller at 5%, but significant. (See Exhibit 3)
By analysing patient spells – segmented by length of stay – we can see how proportions have shifted over time. At Kingston, the percent of patients who stayed at the hospital over 7 days has gone from 30% to 34%. These patients have always consumed an outsized proportion of bed days, but now account for nearly 80% of bed days. (See Exhibit 4)
In doing so, they essentially “squeeze out” shorter-staying patients – illustrated by Exhibit 4 which shows the number of patients staying under 3 days falling 11% from pre-Covid levels. The most extreme change is patients staying over 21 days – 19% more patients fall into this category now, than they did pre-Covid.
There are two reasons why this is happening. Firstly, internal factors related to ward operational effectiveness. Secondly, challenges to do with supported discharges and moving patients onto more appropriate settings of care.
We have witnessed slippage of operational processes on wards – most obviously in terms of board rounds and discharge planning. Both Kingston and Chelsea & Westminster are high-performing Trusts, delivering exceptional care for patients, but there is a need to reinvigorate the relatively straightforward operational elements of this care.
For example, while all elements of the SAFER bundle are discernible during board rounds, they lack the rigour and energy needed to generate proactive discharge planning (including chasing up of delays needed to reduce lengths of stay).
The opportunity here is big, given the cumulative effect of relatively small decreases in aLoS from patients throughout the hospital. But it takes work, and drive. A fatigued workforce, given two years of ongoing pressure (and limited opportunities to reflect, recharge, and re-build their resilience), are normalising delays where they historically may have driven more to achieve patient discharges sooner.
Challenges are exacerbated for patients who require additional support for discharge. Whether it is patients needing intermediate support in their own home (Pathway 1), those needing a short-term rehab and reablement bed (Pathway 2), or those requiring full-time, 24-hour care in a care home facility (Pathway 3), the story is the same. Their aLoS has increased, as it has become more challenging to support them out of hospital into more appropriate care settings.
At Chelsea & Westminster, this change is particularly stark if measured from the lowest point reached mid-pandemic when, due to the urgency needed to rapidly create acute hospital capacity, we actually saw a significant drop in the aLoS of supported discharge patients. Since then, progress has eroded - as of May 2022, aLoS was up 50%.
It is the most complex of supported discharges pathways which have seen the greatest increase in aLoS. At Chelsea & Westminster both Pathways 1 and 2 have seen an increase of over 30% since April 2021, up to 30 days and 28 days respectively.
The reasons for “exit block” and associated delays are varied but can be meaningfully grouped as:
Capacity issues e.g., care home beds closures due to internal outbreaks of Covid, reduced capacity through staffing issues caused by the pandemic and Brexit
Process issues e.g., challenging discharge criteria for patients with Covid or having contacted patients with Covid, and a return to and worsening of pre-Covid levels of supported discharge bureaucracy and paperwork
Assessment units
The disruption at the back of the pathway is amplified toward the middle, as a lack of available beds on inpatient wards make it more challenging to transfer patients onwards through the hospital.
This is clearly seen in the volume of patients transferred onto inpatient wards – down between 15 and 20%. Fewer transfers, as well as a drop in patients being discharge directly, has contributed to a significant aLoS increase on assessment units – up nearly 20% at Kingston. (See Exhibit 5)
The time of day that patients are transferred is also indicative of a change to operational effectiveness. At Kingston nearly 50% of patients move into the main hospital bed base between 8pm and 8am, as they wait for other patients to be discharged, and a bed to become available. (See Exhibit 6)
Impediments to onward flow create delays in availability of beds on assessment units for patients admitted from the ED. It is the bottleneck in this interface which causes the most significant and painful pressure, manifesting in the ED, and generating the greatest risk to patient safety.
Emergency department
Patients remain in the ED for longer than they used to. The aLoS within the ED has increased dramatically, up ~20% to ~50% for Type 1 patients. (See Exhibit 7)
Given attendances are roughly back to pre-pandemic levels, this means that the demand for patient care, as measured in patient hours in the department, has increased significantly. At Kingston, total patient hours in the department increased ~45% between pre- and post-pandemic periods. In the same hospital, if we compare the 2021 mid-pandemic nadir in activity to the first months of 2022, we see a patient hour increase of ~170%. (See Exhibit 8)
Unlike other parts of the hospital, the ED has had to increase its capacity to meet demand – expanding its “elastic walls” by doubling up cubicles, moving patients into overflow areas, and in extreme cases, caring for patients in corridors. It this dynamic which is causing ambulance delays, queuing as they wait to handover.
Congestion in the department has severely impacted staff and patients. Most ED process times have seen an increase in duration of ~50% (e.g., first seen to discharge time increasing 56%, or referral to discharge increasing 50%). The “Decision to Admit” (DTA) to admission time for admitted patients has seen the greatest increase in delays – up 123% at Kingston. (See Exhibit 9)
A useful gauge of the challenge in ED is the number of DTA patients waiting for a bed at 0800; at Kingston, this has increased by over 40%, averaging ~16 each day. Against a total of ~63 daily admissions, this means 26% of the day’s “admission workload” is already in the department before the day shift has even started – up from ~18% pre-pandemic levels.
While 26% is not as extreme as other, more challenged, hospitals post-Covid, it is the “Kingston move” that is significant. This trend is indicative of the new pressures facing EDs in London today. (See Exhibit 10)
A change in patient attributes has added to the pressure articulated by ED teams; patients appear sicker and more complex than pre-Covid. There are two main drivers of this change.
Firstly, during the pandemic, patients were nervous to use services during the peaks of Covid because of either catching Covid themselves or worrying that they would overwhelm those healthcare services. Patient conditions have worsened over time as prevention, diagnosis, treatment, and long-term condition management have been undermined.
Secondly, patients find it difficult to book GP appointments. Or, at the very least, perceive it to be difficult to do so. In either case the outcome is the same: patients turn up sicker, as they have not received any treatment that might have resolved or mitigated their condition at an earlier stage. An additional effect is that patients present to ED who would be more appropriately treated in alternate care settings - explaining why Type 3 attendances have fully recovered to pre-Covid levels unlike Type 1.
In addition, the attitudes and behaviours of patients have shifted. Staff feel increasingly unsafe given increasing instances of abuse, aggression, and the threat of violence. In fact, Chelsea & Westminster has introduced body worn cameras to frontline staff – especially nursing stuff – to cut down the number of incidents and better investigate those that still happen.
The cumulative effect is a pressure-cooker environment in the ED – the root causes of which are not in the direct control of the teams that work there.
Mental health referrals
Repeatedly we heard that increasing prevalence of severe mental health issues was a further source of tension in the ED. We found that, while the number of referrals had actually fallen during Covid by 5-7%, the aLoS of stay for these patients had increased.
At Chelsea & Westminster, from the pre-Covid period, aLoS of mental health patients has increased 14%, up to 7.3 hours. Looking at just the referrals from November 2021, the increase in aLoS is ~40%. (See Exhibit 11)
The number of very long-stayers has increased most dramatically. Chelsea & Westminster has seen a 165% increase in patients waiting between 24 and 36 hours, and ~170% increase in patients waiting over 36 hours. (See Exhibit 12)
It is these patients, who wait in the ED for days at a time and may be familiar faces to the teams on the ground, that have most significantly driven pressure upward.
Covid testing in the emergency department
PCR Covid testing of admitted patients can be a constraint on performance in Emergency Departments. But this is the case only in hospitals that have managed to maintain a relative degree of flow, and which have a strict regimen of testing under which patients are only transferred once results are returned.
Chelsea & Westminster is one such hospital and we have estimated a delay of ~100 minutes was added to the ED LoS of admitted patients. Removing PCR Covid testing (and constraints on transfer) would contribute to a reduction in delays for patients and mitigate overall congestion in the department. In an optimistic scenario, our estimates suggest we might save up to 12 4-hour breaches each day, equivalent to recovering ~30% of the pandemic-driven deterioration in performance.
Increase in complexity of site management
The slippage of operational processes described on wards also appears in management of the whole site. Improvements to bed meetings in particular (including using visual tools and leveraging more reliable data) would help mitigate the effect of a more complex site management function, given new challenges of safe patient allocation and increase in the number of relevant stakeholders to be consulted when taking decisions.
Workforce: Increasing fatigue and decreasing morale
All of the factors described above are underpinned and exacerbated by a decline in staff engagement and hence productivity. Staff resilience has declined in recent months, already eroded to historic lows given the ongoing pressure over the past ~two years.
A significant risk is the negative feedback loop of lower productivity increasing the pressure and challenge within the system, and further undermining staff ability and willingness to step-up to this challenge.
Recommendations
From the outset, the purpose of this piece of work was to not only diagnose new challenges to delivery of Urgent and Emergency Care in London, but also to identify the means of facing up to these challenges.
There are four priority areas to focus on – applicable to London hospitals, and supported by the regional team. It is critical that progress is made in each of these areas before Winter 2022/24.
While it is clear which are the most important areas to focus on, we do not want to be overly prescriptive about specific initiatives. We have ideas and suggestions, but the best solutions will be co-developed at the hospital-level, not stipulated centrally.
Address Supported Discharges challenges
A concerted effort to address challenges in supported discharge is needed, building on the learnings from the national programme on discharges.
The pandemic actually saw a decrease in the bureaucracy associated with discharge in many places – a return to pre-Covid levels of paperwork and delay would be incredibly challenging given the new constraints to performance.
We must also begin to have the conversations at system-level to understand and articulate the dimensions of this challenge, learning from our successes and transfer best practice as a coordinated network of organisations, wherever possible.
Enhance hospital operational ways of working
Individual hospitals will have to work incredibly hard to re-invigorate and revitalise the operational processes which drive flow through and out of the hospital. Programmes will already exist in some hospitals, but focus and energy is needed to restore grip and control before Winter 2022/23.
This work might focus on:
Inpatient operations: Improving board rounds and driving effective MDT discharge planning aligned to SAFER guidelines (for both simple and supported patient discharges)
Acute medicine: Increase discharges; reduce medical response times; effective board round delivery
Emergency Department: 95% non-admitted performance; specialty decision <90 mins; effective 2 hourly huddles in ED; Optimise patient usage of CDU
Real time site management: Manage the timely transfer of patients out of the ED in <4hrs; effective bed and site meetings; live allocation at bed meetings; Constant evaluation of hospital pressures and timely corrective action
Weekend: Increase weekend discharges; create a bed buffer for the weekend; increase usage of the discharge lounge
Address staff morale decline and fatigue
As staff morale decline underpins and exacerbates the other challenges facing UEC, so improving that morale underpins, and will accelerate, the improvements in the other priority areas of focus.
The critical factor here is reversing the command/control dynamic introduced during the pandemic itself, where centralised dicta were necessary to move quickly and with synchronicity in crisis.
Now we must become listeners - and we must genuinely hear our teams – to understand the challenges facing them. And we must do our best to resolve these challenges. In this way we need to begin a meaningful dialogue which is specific and action-oriented.
Seize opportunities for admission avoidance
In addition to enhancing internal ways of working, we know that a big change is needed to manage the inflows into the UEC. The two biggest opportunities come from re-directing activity before it reaches the ED (i.e., working with LAS and community teams to turbo-charge conveyances to alternatives to ED, improving access and perceived access to primary care), and once activity does reach the ED, redirect it to new and proven models of care like SDEC (pursuing both pull and push initiatives to drive throughput).
While the primary responsibility for delivery will be held by local health and social care teams, as the most able agents of change for their specific sites, these initiatives might be supported as four workstreams in a pan-London approach. We might leverage a “field and forum” methodology to codify and propagate best practice and learnings, supporting coordination and collaboration between stakeholders.
Conclusion
The challenges described in this document are significant but not insurmountable.
While pressure has increased – starting at the back, amplifying toward the beginning of the UEC pathway, becoming most visible within the ED – a concerted effort at hospital, system, and regional-level can drive the step-change needed to maintain effectiveness over the next few months, into Winter, and beyond.
The two most important elements of such an effort will be:
Working as a system: we discussed above what actions need to be taken at a system-level to expedite the flow of patients to more appropriate settings of care. In truth, it is the system initiatives which will be the driving force in de-congesting the ED, and alleviating pressures impacted staff and patients.
Within this context, the role of system leaders and provider collaboratives cannot be understated.
People: Over the course of Covid, our people have performed outstandingly in extraordinary circumstances. However, given now they are demoralised and fatigued, any hospital improvement effort cannot be perceived as “one more ask”. Instead, it needs to be the solution to their concerns by providing a more effective and systematic ways of working, and an opportunity for empowerment.
